Staff in an intervention situation looking at monitors showing an angiography image of the aorta and a matching digital twin pre-planned image

“It’s like you can see the postsurgery CT before the intervention” Digital technologies like predictive software solutions can help plan cardiovascular interventions precisely. 

Author: Andrea Lutz 


A patient’s vascular system is as unique as their life. Constitutional or acquired vulnerabilities that lead to aortic diseases like aneurysm or dissection are a major challenge. A thoroughly and precisely planned intervention is a real game-changer for these patients. One approach is the digital twin concept embedded in a hybrid operating environment. 

Antoine Millon, MD, has been working on ways to make treatments less invasive and more successful for years. As Head of the Vascular and Endovascular Surgery Department at Louis Pradel Hospital in Lyon, France, he is at the heart of a collaborative regional network that was created to improve vascular care across the Rhone Alpes Auvergne region. 

Millon strives to build and maintain strong momentum – in his own department and beyond – by contributing to advancing research and innovation, especially in the field of digital technologies applied in the hybrid operating room during endovascular procedures. His personal credo: “Alone we go faster, but together we go further.” For many years, he has participated in a collaboration with PrediSurge, a spin-off company from the Center for Biomedical and Healthcare Engineering at Mines Saint-Etienne, which develops a digital twin concept: predictive software solutions for cardiovascular interventions.

Antoine Millon and his team use the digital twin technology to predict the position of the stent graft during endovascular procedures. 

Millon observes that the number and complexity of endovascular procedures has dramatically increased over the last 20 years [1]: “Endovascular aortic aneurysm repair (EVAR) is a very good example of this stunning evolution. Standard EVAR started in the late 1990s, and there were initially only very few procedures performed per year. Today it represents over 80 percent of elective repairs for infrarenal aneurysms in our department.”

In 2006, Louis Pradel Hospital began to perform complex EVAR and especially fEVAR and bEVAR. “At the beginning, there were less than ten cases per year due to the very steep learning curve and the lack of reimbursement for custom-made devices,” Millon recalls. Starting in 2012, the advent of reimbursement and a collaborative approach were key for increasing the procedure numbers. “Today we perform over 50 fEVAR/bEVAR interventions per year.”

“Assessing the device’s behavior is paramount for procedural planning. Before the advent of digital twin technology, there was no dedicated tool available,” Millon says. “Device behavior was evaluated based on intuition and experience, which requires a high level of specialization.” 

Rigid model of a stentgraft in a persons hands

To design a device for fenestrated endovascular aortic repair, a standard workflow starts with an analysis of the preoperative CT scan by the physician, manufacturers, clinical specialists, and the planning center. “Initially, fEVAR planning was time consuming and labor intensive. The fact that there was no specific tool to evaluate the device’s behavior led to suboptimal accuracy in device design as well as device-related complications.” 

"It took a lot of time to manufacture the stent-graft prototype. We had to perform a test in advance, but the rigidity and opacity of the plastic aorta model sometimes resulted in intraoperative difficulties,” Millon remembers. 

Total image of a physician sitting in front of a monitor with clinical images for planning a fEVAR intervention; hybrid OR setting in the background

“Suboptimal positions increased fenestration and target artery catheterization time – and that sometimes resulted in target artery injury or end-organ failure due to distal embolization. Secondary procedures to repair fenestration-related complications like endoleaks or stenoses were frequent,” Millon says.

Now the digital twin technology allows him to choose the optimal device dimensions and the position of fenestrations and therefore design an optimal strategy for each patient. 

His team can now better plan the length of covered stents deployed across fenestrations, which can prevent complications like Type Ic endoleaks. “It’s like you can see the postsurgery CT before the intervention,” Millon affirms. The workflow is as easy as this: 

"Having a predictive tool has dramatically changed my clinical routine, moving us away from the intraprocedural ‘try and adjust’, thanks to more planning and prediction before the procedure,” says Millon. 

Thanks to improved planning and guidance, patients at Louis Pradel Hospital benefit from “a simpler and more straightforward procedure with better clinical outcomes,” Antoine Millon points out. In his opinion, working in a hybrid OR increases precision because the team benefits from the best image quality with the lowest possible dose. 

The ability to do a 3D CT scan at the end of the procedure is just one of many benefits of working in a hybrid OR that Antoine Millon describes. See what other advantages he experiences when performing complex aortic procedures:

Today the team at Louis Pradel Hospital is enjoying the best of both worlds as their standard: The digital twin technology enables them to anticipate difficulties and adjust the device design preoperatively, and the robotic imaging system allows them to perform a highly efficient procedure. “ARTIS pheno delivers excellent image quality and guides the procedure from start to finish in a low-dose environment. The increased comfort and reduced radiation dose have decreased the intra and postprocedural complication rates for our patients,” says Millon. “There has been a real sense of progress for the entire team since we started using these technologies.” 

Antoine Millon, MD